Management of Specific Fractures Flashcards
What are the clinical signs of a fracture?
Pain Swelling Crepitus Deformity Adjacent structural injury: Nerves/vessels/ligament/tendons
What investigations can be done for a fracture?
X-ray
How do you describe a fracture using X-ray?
Location: which bone and which part of bone? Pieces: simple/multifragmentary? Pattern: transverse/oblique/spiral Displaced/undisplaced? Translated/angulated? X/Y/Z plane
How do fractures Heal?
Bleeding - Blood
Inflammation - neutrophils/macrophages
New tissue formation - fibro, osteo, chondroblasts
Remodelling - Macrophages, osteoclasts, blasts
What are the 3 stages of fracture healing?
Inflammation
Repair
Remodelling
What happens during Inflammation?
Broken bones result in torn blood vessels and the formation of a blood clot or haematoma. The inflammatory reaction results in the release of cytokines, growth factors and prostaglandins, all of which are important in healing. The fracture haematoma becomes organised and is then infiltrated by fibrovascular tissue, which forms a matrix for bone formation and primary callus.
Hours/days
What happens during Repair?
A thick mass of callus forms around the bone ends, from the fracture haematoma. Bone-forming cells are recruited from several sources to form new bone. Soft callus is organised and remodelled into hard callus over several weeks. Soft callus is plastic and can easily deform or bend if the fracture is not adequately supported. Hard callus is weaker than normal bone but is better able to withstand external forces and equates to the stage of “clinical union”, i.e. the fracture is not tender to palpation or with movement.
days-weeks
What happens during Remodelling?
This is the longest phase and may last for several years. During remodelling, the healed fracture and surrounding callus responds to activity, external forces, functional demands and growth. Bone (external callus) which is no longer needed is removed and the fracture site is smoothed and sculpted until it looks much more normal on an x-ray . The epiphyses gradually realign and residual angulation may be slowly corrected.
What happens in primary bone healing?
Intramembranous healing
Absolute stability
Direct to woven bone
What happens in secondary bone healing?
Endochondral healing
Involves responses in the periosteum and external soft tissues
Relative stability
Endochondral ossification: more callus
How long does it take for fractures to heal
3-12 Weeks depending on site
Signs of healing visible on XR from 7-10 days
Phalanges: 3 weeks Metacarpals: 4-6 weeks Distal radius: 4-6 weeks Forearm: 8-10 weeks Tibia: 10 weeks Femur: 12 weeks
What are the general principles of managing fractures?
Reduction - Closed, open
Hold - metal, no metal
Rehabilitate, Move, physiotherapy, use
What are the principles for closed holding?
plaster
traction - skin/skeletal
What are general fracture complications?
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)
What are specific fracture complications?
Neurovascular injury Muscle/tendon injury Non union/mal union Local infection Degenerative change (intraarticular) Reflex sympathetic dystrophy
What are the factors that affect tissue healing?
Mechanical - movement, forces
Biological - Blood supply, Immune function, Infection, Nutrition
What are causes of Fractured neck of femur?
Osteoporosis (older)
Trauma (younger)
Combination
What would you do in an extra capsular NoF fracture?
minimal risk to blood supply and AVN: fix with plate and screws (Dynamic hip screw)
What would you do in an intracapsular NoF fracture?
Intracapsular: if undisplaced: less risk to blood supply: fix with screws
If displaced: 25-30% risk AVN: replace in older patients; fix if young
What is the presentation of a shoulder fraction?
often direct trauma
pain
restricted movement
Loss of normal shoulder contour
What would be the clinical examination for a shoulder dislocation?
Assess neuromuscular status - axillary nerve
What investigations would you do in a shoulder dislocation?
X-ray prior to manipulation, identify fracture e.g. humeral neck, greater tuberosity avulsion/glenoid.
Scapular Y view/modified axillary
What is the management for a dislocated shoulder?
Vigorous manipulation should be avoided to prevent fractures.
Best method is traction/counter-traction and gentle internal rotation disimpact humeral head.
Make sure patient is relaxed + safe environment.
If alone use Stimson method
What is the management for a distal radius fracture?
Cast - Temporary, reduction of fracture + placement into cast until definitive fixation.
MUA & K-wire - Fractures that are extra-articular + instability, especially in children, MUA in theatre + K-wire, remove wires post-op in clinic.
ORIF - Displaced, unstable fracture, open reduction internal fixation with plate + screws.
When would treatment be non-operative for Tibial plateau fractures?
Truly undisplayed fractures with good joint line congruency assessed on CT/ high fidelity imaging.
When would treatment be operative for Tibial plateau fractures?
Predominant
restoration of articular surface using combination of plate/screws.
Bone graft/cement may be necessary to prevent further depression after fixation
What is the non operative management for an ankle fracture?
Non weight bearing below knee cast for 6-8 weeks, walking boot then physiotherapy to improve range of motion.
Weber A below syndesmosis & therefore though to be stable.
Weber B if no evidence of instability ( medial/posterior malleolus fracture and no taller shift)
What is the operative management for an ankle fracture?
Soft tissue dependent - patient needs strict elevation due to injury swelling.
Open reduction internal fixation +/- syndesmosis repair using either screw or tightrope technique, screws can be left in situ but may break in time so will be removed
Weber B - unstable fractures - talar shift/medial or posterior malleoli fractures
Weber C - Fibular fracture above the level of the syndesmosis therefore unstable.
